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Placenta accreta spectrum disorders, particularly placenta percreta, present significant surgical challenges due to the high risk of life-threatening hemorrhage, maternal morbidity, and potential involvement of pelvic organs.1 2 In Lebanon, the incidence of placenta accreta spectrum has increased alongside rising cesarean section rates.3 Surgical management of placenta percreta often entails intricate pelvic dissection in areas with altered anatomy due to both pregnancy and placental invasion of other organs and significant abnormal vascularization. To achieve successful outcomes through cesarean hysterectomy, surgeons must adopt a strategic approach that prioritizes the prevention of urologic injuries, employs techniques for controlling difficult bleeding and, when suitable, considers conservative management options.4
To address this, the gynecologic oncology team at Hôtel-Dieu de France University Hospital in Beirut has developed a structured multidisciplinary protocol for managing patients with placenta accreta spectrum. This protocol prioritizes comprehensive pre-operative imaging with systematic MRI and collaborative surgical planning with urologists and anesthesiologists and systematic pre- and intra-operative ultrasonography guiding the hysterotomy site to minimize bleeding. When conservative management is not a viable option, a standardized surgical technique adapted from gynecologic oncology was developed by Atallah et al5 to perform cesarean hysterectomy while emphasizing on a retroperitoneal and posterior first approach. This approach aims to secure the ureters and involves clipping the uterine arteries at their origin and securing the uterine veins. The procedure includes dissecting the recto-vaginal space and making a posterior first vaginal wall incision with the help of a flat retractor inserted vaginally to facilitate the lifting of the uterus (Figure 1). Bladder separation is performed next, with sometimes a cystotomy or partial resection if severe adherence or bladder involvement is present. An anterior vaginal incision is then made to allow for the complete removal of the uterus using clamps along the cervix (Figures 2 and 3). This technique provides optimal vascular control and strategic dissection, minimizing complications such as excessive bleeding and bladder injury.6
The involvement of gynecologic oncologists has proved crucial in reducing the need for emergent procedures and decreasing peri-operative morbidity. Early involvement of gynecologic oncologists has consistently been associated with lower estimated blood loss, fewer transfusions, and better maternal outcomes.
The Lebanese Percreta Group was established in 2007 by three gynecologic oncologists from the major university hospitals in Lebanon (Figure 4). The primary goal was to create a multidisciplinary model to improve the management of placenta accreta spectrum disorders. Over the years, this model has successfully led to standardized approaches in the management of placenta accreta spectrum, focusing on collaborative care involving obstetricians, gynecologic oncologists, and other healthcare professionals in a multidisciplinary approach.7 The group has been active in organizing educational initiatives, such as workshops and conferences, to share knowledge and promote this collaborative practice. The integration of gynecologic oncology expertise highlights the importance of specialized surgical teams in managing complex cases like placenta percreta. Through innovative protocols and a focus on teamwork, the team has set new standards for placenta accreta spectrum management in Lebanon, contributing to safer maternal outcomes and addressing a growing public health concern.
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Acknowledgments
We extend our gratitude to Dr Muhieddine Seoud and Dr Rabih Chahine for their pivotal role in co-founding, along with Dr David Atallah, the Lebanese Percreta Group.
Footnotes
X @housseinelhajj3
Contributors Conceptualization and design: DA, HEH, NK. Data collection or acquisition and analysis: HEH, NK, YA, MM. Writing the manuscript or report: HEH, DA, MM. Review and editing: HEH, DA, MM, YA, NK. Supervision: DA.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.